Form Soc 157a - Supervised Independent Living Placement (Silp) Approval And Placement Agreement
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1
2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SUPERVISED INDEPENDENT LIVING PLACEMENT (SILP)
APPROVAL AND PLACEMENT AGREEMENT
CASE #:
NAME:
DATE OF PLACEMENT:
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
SECTION A: SILP PLACEMENT TYPE (Please check the option that best describes the young adult’s placement.)
Youth lives:
(can check more than one)
I
Apartment rental
I
Alone
I
Apartment Rental (young adult on lease, living alone)
With:
I
Lease
I
I
Parent
Friend(s)
I
I
Is youth on lease?
Yes
No
I
I
Family member(s)
Stranger(s)
If applicable, who else is on the lease?
I
I
______________________________
NREFM(s)
Landlord(s)
______________________________
I
Co-parent
I
Month-to-month
I
Other: ___________________________________
I
Room rental
Youth lives with a Support Person (someone who is
From: _________________________
providing training and/or support to the youth in one or
Relationship to youth:
more areas, such as budgeting):
______________________________
I
I
Yes
No
I
Single room occupancy hotel (SRO)
If yes, who: ___________________________________
Relationship to youth: ___________________________
Housing exempt from Checklist of Health and Safety
I
NMD has been advised on how to negotiate a shared living
Standards as listed on the SOC 157B
agreement with their support person, roommate, etc.
(case worker still completes the SOC 157A and B forms):
I
NMD agrees to inform case manager of any roommate
I
University/College approved housing
changes. An update to this form is not necessary unless
I
Tribal SILP
loss of a roommate(s) means NMD won’t be able to cover
the rent. In that case, a new living arrangement should
I
Job Corps/AmeriCorps/California Conservation Corps
be made.
(circle which one)
(if living in onsite housing)
I
Adult residential treatment facility (ARTF)
Type: _________________________
I
Sober living arrangement/home (SLA/SLH)
I
Other: ________________________
SECTION B: SILP READINESS
I
Annual SILP re-assessment - no readiness assessment needed
I
NMD living in exempt housing as indicated above – no readiness assessment needed
I
Based on the readiness assessment, for this proposed SILP, NMD is:
I
Ready for the proposed SILP
I
Ready for the proposed SILP with assistance from the support person listed in Section 1
I
Not ready for the proposed SILP - the NMD’s TILP will be updated to include goals to assist the NMD in
becoming ready for a SILP
A new readiness assessment will be completed in ___________ months
DATE:
SIGNATURE OF SOCIAL WORKER/PROBATIONS OFFICER:
I
I
I
I agree with the SILP Readiness Assessment
I disagree with the SILP Readiness Assessment
No readiness assessment needed.
DATE:
SIGNATURE OF YOUNG ADULT:
I
F YOUNG ADULT HAS BEEN ASSESSED AS NOT READY FOR SILP AT THIS TIME - GO TO SECTION H
STOP
SOC 157A (8/17)
PAGE 1 OF 2
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